Wesco Insurance Enrollment

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Covered Driver:
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By signing this Request for Insurance Enrollment Form I agree to all of the following:
I certify that I am an Owner Operator paid on a 1099 performing contracted services pursuant to written agreement, in a position to incur profit or loss, and determine the method, manner and means to perform my work assignment.
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I shall make such premium payments as may be required for the program for which I am enrolling.
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That all of the statements made in this Request are, to the best of my knowledge and belief, true and accurate.
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I certify that I am a Contract Driver paid on a 1099 performing contracted services pursuant to written agreement, in a position to incur profit or loss, and determine the method, manner and means to perform my work assignment.
I shall make such premium payments as may be required for the program for which I am enrolling.
I shall make such premium payments as may be required for the program for which I am enrolling.
OR
That all of the statements made in this Request are, to the best of my knowledge and belief, true and accurate.
(Signature of Covered Driver)
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